A new study[1]suggests that one of the best ways to combat the chronic underreporting
of concussion by athletes may be to educate coaches on ways to create an environment where athletes feel safe reporting concussion symptoms. It adds to a
growing body of evidence challenging the conventional wisdom that
inadequate athlete concussion knowledge is the
principal barrier to increased reporting, and that other ways need to be found to keep athletes safe, including enlisting coaches and parents in creating an environment in which concussion symptom reporting is encouraged.

Researchers at the Harvard School of Public Health and Boston University's Center for the Study of Traumatic Encephalopathy concluded, based on responses to questionnaires completed by male NCAA Division 1 hockey players, that the NCAA's general mandate that
student-athletes be provided with "educational material on concussions"
was ineffective.

Not only did such mandate fail to yield significant improvements in knowledge among the players after receiving written materials about
concussion, but their receipt of such information did virtually nothing to change their intention to continue
playing while experiencing symptoms of a concussion, which, studies
show, puts athletes at increased risk of a longer concussion recovery time and
adverse neurological consequences.

"Existing education programs for athletes have tended to focus on
symptom identification and reporting protocol, with evaluation largely
assessing change in concussion knowledge," writes
lead author Emily Kroshus of the Department of Social and Behavioral
Sciences at the Harvard School of Public Health, but "[g]iven that the goal of concussion education is to
change player behavior (eg, ceasing play when symptoms are present),
concussion knowledge may not be the best or only factor to target."

Instead, Kroshus and her colleagues recommend that concussion education focus more on the coach's critical role in facilitating concussive symptom reporting by communicating to athletes positive messages about concussion reporting, by fostering a "culture of safety," and by creating channels for reporting through a variety of formal and/or informal means.

Attitude: more important than knowledge?

Until recently, the conventional wisdom of concussion experts has been that the principal reasons for the chronic under-reporting by athletes of
concussive symptoms is inadequate athlete concussion knowledge, and that
increased concussion education - as is mandated by the NCAA and laws in
almost every state - would likely remove the primary barrier to concussive symptom reporting.

As in the current study, a 2013 qualitative focus group study involving 50 athletes from three
football, two boys' soccer, and four girls' soccer teams, researchers at
Seattle Children's Hospital and the University of Washington found that
athlete concussion knowledge was not the most important barrier to
concussive symptom reporting.[3] Rather, wrote Sara P. Chrisman, M.D., M.P.H., the lead author of the Washington State study, it was that athletes were
hesitant to report concussive symptoms out of concern as to how their
reports would be received by their coach.

Most athletes, found Chrisman and her colleagues, "seemed to know a
great deal about concussion. They could report a large number of signs and symptoms
and they recognized the danger of concussion, mentioning risks of long
term disability or death." (such high level of concussion knowledge may
have been, Chrisman speculated, the result of the increased concussion
education required under Washington State's groundbreaking Lydstedt Law). But nearly every one of the nine focus groups, she and her colleagues found, "came
to the conclusion that they would keep playing when faced with a
hypothetical scenario in which they were experiencing concussive
symptoms ... after a collision."

Consistent with the result of the NCAA hockey study and a number of
other studies over the past decade, as well as anecdotal evidence about
concussion reporting attitudes gathered during MomsTEAM's filming of its
high school football concussion documentary, "The Smartest Team," most athletes in the Washington State focus groups gave as reasons for choosing to continue playing while experiencing symptoms that:

they did not want to stop playing or be pulled from the game;

they questioned whether the symptoms, many of which are not
specific to concussions (e.g. headache, dizziness, nausea), could have been caused by something other than
concussion;

it was not acceptable to leave the game for nonspecific symptoms of
a concussion because if they were wrong, the coach might punish them for reporting by removing them a starting position, reducing future playing time, or inferring that reporting concussive symptoms made them "weak" (a
sentiment expressed by both soccer and football players, male and female);

they didn't want to let the team down; and

they had received negative messages from coaches regarding injury
reporting (although, to be fair, some reported having received positive
messages from coaches regarding concussive symptom reporting).

Developing trend

The NCAA hockey study thus becomes just the latest in a series of recent studies[2-5]
suggesting that one of the best ways to combat underreporting by
athletes of concussion symptoms may be to shift the focus of educational
efforts towards helping coaches facilitate concussion
reporting, the theory being that athletes will be more likely to report
concussion symptoms if they no longer think that they will be punished
by the coach for reporting, such as by losing playing time or their
starting position, perceived by their teammates as letting them down, or
viewed by their coach as "weak," all of which have been documented in
numerous studies over the past decade as reasons athletes are reluctant
to report concussion symptoms.[2-9]

Its recommendations build on those made by Chrisman and her colleaguesin their study in which they proposed that efforts to increase concussion reporting utilize the Theory of Planned Behavior (TPB)[10] which, in the context of concussion reporting behavior, holds that such behavior is determined by the interplay of three factors:

Attitudes: athletes' beliefs about the consequences of reporting concussion symptoms;

Subjective norms: beliefs about what others (especially coaches, but also parents and eammates) expect the athlete to do; and

Chrisman found that, contrary to the conventional wisdom, "athletes did not report concussive symptoms because of a lack of knowledge" [they found that high school soccer and football players seemed to know a great deal about concussions, could report a large number of signs and symptoms many of which they had personally experienced - and recognized the danger of concussion, mentioning risks of long term disability or death], but, rather because, despite understanding "the risk of playing with concussive symptoms (attitudes), they believed that [coaches] did not want them to report symptoms (subjective norms), and those norms had a greater influence on their behavior than their own perceived ability to report concussive symptoms.

"In other words," Chrisman concluded, "athletes' intentions to report concussive symptoms followed the norms for what was acceptable regarding concussive symptom reporting, even when these norms went against their own concussion knowledge. These norms, in turn, were based on athletes' perceptions of coach expectations regarding symptom reporting."

"The biggest barrier to concussive symptom reporting is that adolescents are designed to be risk takers," argues Chrisman. "Adolescents know concussions are dangerous, but they play anyway. The same has been found for cigarette smoking, alcohol use and driving while intoxicated. Adolescent risk-taking is not a new finding," she says, but, unfortunately, it "is also not susceptible to change."

"Our intent was to remind people that educating youth about the dangers of concussion is unlikely to improve concussion reporting. Instead, we must find other ways to make them safe. We focused on coaches because this is an area where change is possible. Coaches should be an ally in this discussion. Our experience has been that the vast majority of high school football and soccer coaches are very knowledgeable about concussion and willing to do all that is possible to ensure the safety of their athletes."